Acceptance and Commitment Therapy Steven C. Hayes University of Nevada

Acceptance and Commitment Therapy It is said as one word, not letters A cognitive behavioral intervention that uses acceptance and mindfulness processes, and commitment and behavior change processes, to create psychological flexibility

Psychological Flexibility … is consciously contacting the present more fully, without needless defense, and based on what the situation affords, changing or persisting in behavior in the service of chosen values.

ACT Is transdiagnostic: focused on common core processes known to underlie many forms of psychopathology This makes it broadly applicable, and especially well suited to multi-problem patients

Expanding avoidance All animals escape and avoid aversive events

But only humans can readily bring aversive events into any setting “Car” CAR

So We Try to Avoid Pain Itself Experiential avoidance is built into human language and then amplified by the culture Experiential avoidance is the tendency to attempt to alter the form, frequency, or situational sensitivity of historically produced negative private experience (emotions, thoughts, bodily sensations) even when attempts to do so cause psychological and behavioral harm

ACT This is a logical step, but it tends to amplify pain or at least its impact, not decrease it Especially toxic for those with difficult histories or physiology Why toxic?

Self-Amplifying Don’t think of a white bear Don’t be anxious Consequences: artificial pain

Puts Life on Hold what can happen when we let the monster dictate how we live. Nobody wants to spend their time and energy on this roundabout, but it is so easy to do. In fact, this cartoon doesn’t even show how crowded this round about really is?

Increases Arousal and Stress And with that we respond not just psychologically but physically! Strongly!

Repertoire Narrowing And as aversive control increases, liberty leaves Organisms respond to aversive with repertoire narrowing

The ACT Model An ACT Model of Treatment/Health Psychological Flexibility

An ACT Model of Treatment Open An ACT Model of Treatment

An ACT Model of Treatment Centered An ACT Model of Treatment

An ACT Model of Treatment Engaged An ACT Model of Treatment

Empirically ACT is recognized as an evidence-based therapy by APA and SAMSHA (areas so far: depression; chronic pain; coping with psychosis; worksite stress; OCD) 40 RCTs 42 component studies; 38 mediation studies Over 150 studies on experiential avoidance and psychological flexibility

What is Remarkable about the ACT Literature The variety of problems it can help treat The range of formats that can be used Size and stability of outcomes in comparison to the extent of intervention

Controlled Studies in Mental Health Obsessive-compulsive disorder; generalized anxiety disorder; panic disorder; depression; polysubstance abuse; coping with psychosis; borderline personality disorder; trichotillomania; marijuana dependence; skin picking; eating disorders

Controlled Studies in Behavioral Medicine chronic pain; smoking; diabetes management; adjustment to cancer; epilepsy; whiplash associated disorders; chronic pediatric pain; weight-maintenance; exercise; work stress; adjustment to tinnitus;

ACT for Depression

ACT for COD

ACT / CBT Comparisons 8 ACT better 1 CBT better 3 Both are the same Change processes so far always different

ACT for Psychosis

ACT (etc) for BPD (Gratz et al 2006) Small RCT (N = 22); patients with at least 5/9 DSM BPD features (8 or more on the RDIB) History and current (last 6 mo) self- harm In individual therapy (stayed in – the group was in addition) 14 weekly groups; 90 minutes each

ACT (etc) for BPD (Gratz et al 2006) 1. Function of self-harm behavior 2. Function of emotions 3-4. Emotional awareness 5. Primary vs. secondary emotions 6. Clear vs. cloudy emotions 7-8. Emotional avoidance vs. acceptance 9. Nonavoidant emotion regulation strategies 10. Impulse control 11-12. Valued directions 13-14. Commitment to valued actions

Self Harm 30 20 TAU Mean Score ACT etc 10 Pre Post Phase

Depression 30 20 TAU Mean Score ACT etc 10 Pre Post Phase

ACT for BPD (Morton et al., in press) Small RCT (N = 41); patients with at least 4 DSM BPD features Regular individual treatment contact (stayed in – the group was in addition) 12 weekly groups; 2 hours each

ACT for BPD (Morton et al in press) 1. Overview of ACT. Intro to mindfulness 2. Cost of avoidance; beginning values 3-4. Acceptance and defusion 5. Mindfulness of pleasure 6. Emotional awareness 7-8. Health and relationship values 9. Mindfulness in conflict 10. Values and choice 11. Mindfulness and acceptance 12. Review and celebration

Borderline Severity TAU Mean Score ACT Phase 50 40 30 Pre Post 3 mo F-Up Phase

Hopelessness 18 TAU 12 Mean Score ACT 6 Pre Post 3 mo F-Up Phase

Impact of ACT Self Help Sub-analysis of 46 depressed teachers in a wellness program 8 weeks to read the book The treatment protocol consists of an 8-week trial period in which participants have access to 6 10-point quizzes completed online at will and at each participant's pace within that time. Standardized email feedback is given between 1 and three days after each quiz completion. Feedback consists of a score, missed item numbers, and a 1-word score-contingent response such as Super for a 10, great for a 9, or good for an 8.. 33

Depressed Teacher Subsample Average for Hospitalized Depressed Patients Book Analysis of 0,2,6 month data: p eta sq = .25 (large effect size) Teacher Sample How about clinical significance? % who get across that green line Book O 2 6 8 Depressed Teacher Subsample

Depressed Teacher Subsample Percentage Clinically Improved 56.5% Book Depressed Teacher Subsample

ACT Good books now available in Dutch, for example Rokx, T.A.J.J. (2011). Het Leven is geen Feest; de mythe van het maakbare geluk. Amsterdam, Hogrefe.